Raymond H Chan1, Barry J Maron1, Iacopo Olivotto1, Michael J Pencina1, Gabriele Egidy Assenza1, Tammy Haas1, John R Lesser1, Christiane Gruner1, Andrew M Crean1, Harry Rakowski1, James E Udelson1, Ethan Rowin1, Massimo Lombardi1, Franco Cecchi1, Benedetta Tomberli1, Paolo Spirito1, Francesco Formisano1, Elena Biagini1, Claudio Rapezzi1, Carlo Nicola De Cecco1, Camillo Autore1, E Francis Cook1, Susie N Hong1, C Michael Gibson1, Warren J Manning1, Evan Appelbaum1, Martin S Maron2. 1. From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.). 2. From the PERFUSE Study Group, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (R.H.C., S.N.H., C.M.B., W.J.M., E.A.); Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, MN (B.J.M., T.H., J.R.L.); Referral Center for Myocardial Diseases, Azienda Ospedaliera Universitaria Careggi, Florence Italy (I.O., F.C., B.T.); Harvard Clinical Research Institute and Boston University Biostatistics, Boston, MA (M.J.P.); Ospedale Sant'Andrea Universita "La Sapienza," Rome, Italy (G.E.A., C.N.D.C., C.A.); Division of Cardiology, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada (C.G., A.M.C., H.R.); Hypertrophic Cardiomyopathy Center, Division of Cardiology, Tufts Medical Center, Boston, MA (J.E.U., E.R., M.S.M.); Fondazione C.N.R./Regione Toscana G. Monasterio, Pisa, Italy (M.L.); Ente Ospedaliero Ospedali Galliera, Genoa, Italy (P.S., F.F.); Policlinico S. Orsola-Malpighi, Bologna, Italy (E.B., C.R.); and Department of Epidemiology, Harvard School of Public Health, Boston, MA (E.F.C.). mmaron@tuftsmedicalcenter.org.
Abstract
BACKGROUND: Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death in the young, although not all patients eligible for sudden death prevention with an implantable cardioverter-defibrillator are identified. Contrast-enhanced cardiovascular magnetic resonance with late gadolinium enhancement (LGE) has emerged as an in vivo marker of myocardial fibrosis, although its role in stratifying sudden death risk in subgroups of HCM patients remains incompletely understood. METHODS AND RESULTS: We assessed the relation between LGE and cardiovascular outcomes in 1293 HCM patients referred for cardiovascular magnetic resonance and followed up for a median of 3.3 years. Sudden cardiac death (SCD) events (including appropriate defibrillator interventions) occurred in 37 patients (3%). A continuous relationship was evident between LGE by percent left ventricular mass and SCD event risk in HCM patients (P=0.001). Extent of LGE was associated with an increased risk of SCD events (adjusted hazard ratio, 1.46/10% increase in LGE; P=0.002), even after adjustment for other relevant disease variables. LGE of ≥15% of LV mass demonstrated a 2-fold increase in SCD event risk in those patients otherwise considered to be at lower risk, with an estimated likelihood for SCD events of 6% at 5 years. Performance of the SCD event risk model was enhanced by LGE (net reclassification index, 12.9%; 95% confidence interval, 0.3-38.3). Absence of LGE was associated with lower risk for SCD events (adjusted hazard ratio, 0.39; P=0.02). Extent of LGE also predicted the development of end-stage HCM with systolic dysfunction (adjusted hazard ratio, 1.80/10% increase in LGE; P<0.03). CONCLUSIONS: Extensive LGE measured by quantitative contrast enhanced CMR provides additional information for assessing SCD event risk among HCM patients, particularly patients otherwise judged to be at low risk.
RCT Entities:
BACKGROUND:Hypertrophic cardiomyopathy (HCM) is the most common cause of sudden death in the young, although not all patients eligible for sudden death prevention with an implantable cardioverter-defibrillator are identified. Contrast-enhanced cardiovascular magnetic resonance with late gadolinium enhancement (LGE) has emerged as an in vivo marker of myocardial fibrosis, although its role in stratifying sudden death risk in subgroups of HCM patients remains incompletely understood. METHODS AND RESULTS: We assessed the relation between LGE and cardiovascular outcomes in 1293 HCM patients referred for cardiovascular magnetic resonance and followed up for a median of 3.3 years. Sudden cardiac death (SCD) events (including appropriate defibrillator interventions) occurred in 37 patients (3%). A continuous relationship was evident between LGE by percent left ventricular mass and SCD event risk in HCM patients (P=0.001). Extent of LGE was associated with an increased risk of SCD events (adjusted hazard ratio, 1.46/10% increase in LGE; P=0.002), even after adjustment for other relevant disease variables. LGE of ≥15% of LV mass demonstrated a 2-fold increase in SCD event risk in those patients otherwise considered to be at lower risk, with an estimated likelihood for SCD events of 6% at 5 years. Performance of the SCD event risk model was enhanced by LGE (net reclassification index, 12.9%; 95% confidence interval, 0.3-38.3). Absence of LGE was associated with lower risk for SCD events (adjusted hazard ratio, 0.39; P=0.02). Extent of LGE also predicted the development of end-stage HCM with systolic dysfunction (adjusted hazard ratio, 1.80/10% increase in LGE; P<0.03). CONCLUSIONS: Extensive LGE measured by quantitative contrast enhanced CMR provides additional information for assessing SCD event risk among HCM patients, particularly patients otherwise judged to be at low risk.
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